The following applies to self-funded plans:

  • Prohibition of lifetime limits
  • Dependent to age 26 coverage
  • No preexisting condition exclusion for those under age 19
  • Prohibition against rescission for other than fraud
  • Emergency services always covered in network regardless of provider
  • Using any network doctor as a primary care physician (PCP)
  • Summary of Benefits and Uniform Glossary (SBC)
  • W-2 reporting for employers who send at least 250 Forms W-2
  • Premium tax to fund comparative effectiveness research program
  • New plans must have established internal claims appeal process and external review procedures
  • Employer Play or Pay
  • Minimum Value as opposed to Actuarial Value which applies to fully-insured
  • individual and small group plans.

The following do not apply to self-funded plans:

  • Essential Health Benefits (large groups and self-funded plans must provide at least a 60% minimum value, but are not required to meet any specific actuarial values)
  • Premium taxes on insurers which will be passed on to consumers
  • Internet enrollment portal
  • Medical loss ratios and rebating
  • Premium rate review

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